Wyoming Family Dental
HIPPA-NOTICE OF PRIVACY PRACTICEPatient Name_____________________________________________Date of Birth__________________HIPPA is federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practice is to explain how WYOMING DENTAL may use or disclose your health care information. The notice also explains the rights that you are guaranteed under HIPPA regulations.WYOMING DENTAL may contact you and leave detailed messages at the following numbers:Cell:__________________________________ Home:________________________________Work:________________________________ Other:_________________________________This authorization allows WYOMING DENTAL to discuss all aspects of my protected health information with individuals listed below:NameRelationshipPhone Number_____________________________________________________________________________________All professional services rendered are charged to the patient. Necessary forms will be completed by WYOMING DENTAL to help expedited insurance carrier payments. However, the patients are responsible for all fees regardless of insurance coverage.I understand my signature authorizes releasing of the information to the insurer or agency given to WYOMING DENTAL for health insurance plans. Signing below indicates that you have received and understand the Notice of Privacy Practice. If you have any questions, please contact our HIPPA Compliance Office listed below:Ali Timmons: P.O. BOX 189 WYOMING, MN 55092Signature of patient or legal representative_____________________________________________________Date__________________Relationship to patient if legal representative is signing________________________________________________ ................
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